Diagnosis and Treatment of Diabetes-related Foot and Ankle Problems

EndocrineWeb spoke with Dr. Nere Onosode about the diagnosis and treatment of diabetes-related foot and ankle problems. Dr. Onosode is a Doctor of Podiatric Medicine and board-qualified by the American Board of Foot and Ankle Surgery. Here, he answers the many questions of interest to people with diabetes.

As a reconstructive surgeon, what types of foot disorders do you treat?
Dr. Onosode: I treat all types of foot and ankle disorders, including toe and forefoot deformities to large Charcot deformities. Diabetes is the number one cause of Charcot foot deformity in America, and is a major complication of diabetes.

Charcot foot and/or ankle may develop as a result of peripheral neuropathy. The bones weaken and cause microfractures that can become large fractures leading to foot/ankle deformity. The bony displacement of small or large fractures erodes soft tissues leading to an open sore, ulceration, and infection. Left untreated, amputation may be necessary.

What should a patient expect when they come to you with a diabetes-related foot (or ankle) problem?Dr. Onosode: For patients with diabetes, I acquire an in-depth medical history and perform a comprehensive physical and neurological examination, including a CDFE—a Complete Diabetic Foot Examination. The CDFE includes an orthopaedic, vascular, neurologic, and dermatologic examination.

During the orthopaedic exam I check for bony prominences, and any sign of deformity affecting the toes (digits), middle and back of each foot, ankles, and lower legs. I want to be aware of any hard or soft tissue that can lead to ulceration, infection, and potentially amputation and quickly address any problems.

Patients with long-standing diabetes can be at risk for vascular problems in the lower extremities. This is called arterial and venous insufficiency. I examine the pulses from the legs downward through the toes.

During the dermatologic exam, I look for any breaks in the skin, including fissures (skin tears). Again, from the legs downward through the toes.

The examination includes a centralized monofilament test and tuning forktest to measure feeling from the knee to the toes; to make sure sensation is intact as compared to other extremities. Here, I am looking for signs of peripheral neuropathy.

The monofilament test is painless and utilizes a single blunt-tipped flexible wire. The purpose of the test is to judge the patient’s ability to feel. To help distinguish normal from abnormal (lack or loss of feeling) feeling, the filament is first used to gently touch the patient’s hand; this helps the patient to know (1) the test is painless and (2) what normal feels like. Throughout the test, the patient is asked if they feeling anything.

Typically, what types of treatments do you provide people with diabetic-foot problems?Dr. Onosode: Non-operatively, the most important is counseling patients about diet and exercise. Controlling blood glucose is paramount. Patients receive counseling verbally and in written form to help them improve glucose management, and make necessary lifestyle, diet and exercise changes. People with diabetes need to wear the correct type of shoe for their foot type. I can help in this area too.

On the surgical side of treatment, I want to make sure any bony or soft tissue abnormalities are corrected because these patients are at high risk for ulcerations, infections, and potential amputations. I can reconstruct the foot arch, toes, and foot and ankle bones to ensure there is adequate soft tissue coverage, and the feet and ankles are in proper alignment. These corrective measures help to reduce the risks for future problems.

Is proper footwear a challenge for some patients with diabetes?Dr. Onosode: Yes, even for my nondiabetic patients. It is critical patients know what their foot type is and choose shoes accordingly. The foot types are: high-arch (or cavus foot), neutral arch, and low-arch foot (or valgus foot).

Shoe recommendations by foot type:

High-arch foot: a shoe with shock absorption and less motion control

Neutral foot: a shoe with less stability control and more shock absorption

Low-arch foot: a shoe that provides more stability and motion control

In shoe selection, I emphasize shoes with extra depth, a wide toe box, and arch support. It is extremely important for the pressure points of the feet and ankles to be off-loaded. An extra depth shoe with a heel cushion and wide toe box helps reduce pressure between the forefoot and toes. Arch supports reduce ground reaction forces and helps eliminate pressure points that can prevent skin breakdown, ulceration, and infection.

Unfortunately, for the majority of people, insurance does not cover the cost of prescriptive strength accommodative shoes. Medicare may offer some coverage for patients who qualify.

Please Note: If you have diabetes, please talk with your treating physician about a referral to a podiatrist. A podiatrist is an essential member of your diabetes care team.

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